Medical History

Name(Required)

First Last

Date of Birth

Month

Day

Year

Age

Height

Weight

Who referred you to our practice?

Have any of your family members been treated here?

Yes

Why are you seeing the doctor today?

When did you first have this problem?

General Health

Recurrent infections

Recurrent fever

Fatigue

Night sweats

Recent weight gain

Recent weight loss

Decreased appetite

No problems

Skin

Sores

Hair loss

Non-healing wound

Changes in moles

New lesions

Burn trauma

Rash

Lumps/growths

No problems

Head, Ears, Eyes, Nose, Throat

Ear infections

Nose bleeding

Cataracts

Sore throat

Seasonal allergies

Eye infections

Headaches

Corrective lenses

Blurred vision

No problems

Lung

Difficulty breathing

Cough

Sleep with more then 1 pillow

Cough blood or mucus

Wheezing

No problems

Breast

Breast lump/mass

Nipple discharge

No problems

Breast pain

Nipple pain

Abnormal mammogram

Breast swelling

Skin changes

Heart

Chest pain

Tightness

Thumping or pounding

Heart murmur

Swollen arms or legs

Shortness of breath

Rheumatic fever

High blood pressure

No problems

Stomach and Intestinal

Special diet

Heartburn

Rectal bleeding

Nausea

Indigestion

Blood in stool

Vomiting

Black stools

Positive hemoccult

Ulcers

Constipation

Diverticulosis

Difficulty swallowing

Diarrhea

Diverticulitis

No Problems

Male Reproductive

Painful urination

Frequency

Impotence

Prostate problems

Urgency

Testicular pain

No problems

Female Reproductive

Painful urination

Frequency

Blood clots

Irregular periods

Urgency

No problems

Muscle, Bone, Joint

Joint pain

Neck pain

Muscle cramping

Muscle pain

Joint stiffness

No problems

Back pain

Joint swelling

Nervous System

Seizures

Decreased memory

Problems speaking

Dizziness

Fainting

Problems moving

Loss of consciousness

No problems

Veins (blood vessels), Lymphatic

Abnormal bleeding

Easy bruising

No problems

Anemia

Enlarged lymph nodes

Allergies

Are you allergic to any medications, prescribed or over the counter?

Yes

If yes, please list medication and the reaction you had.

(Include aspirin, Tylenol, vitamins, over the counter medications, herbal remedies, supplements etc.)

Are you allergic to any contacts such as latex, adhesive tape or betadine?

Yes

If yes, please list the contact and the reaction you had

Are you allergic to any foods?

Yes

If yes, please list food and the reaction you had.

FAMILY HISTORY

Are there diseases or illnesses that family members have had? Please check the boxes below for any family member who has had the problem. Under siblings please write brother or sister. Under Grandmother please write maternal (mother)or paternal (father). Under Grandfather please write maternal (mother) or paternal (father).

Anesthetic Problems

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Cancer - Breast

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Cancer - Colon

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Cancer - Endometrial

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Cancer - Ovarian

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Cancer - Pancreatic

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Cancer - Other

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Diabetes

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Heart Disease

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

High Blood Pressure

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Melanoma

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Mental Illness

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Stroke

Mother

Father

Brother

Sister

Grandmother - Maternal

Grandfather - Maternal

Grandmother - Paternal

Grandfather - Paternal

Children

Cousins

Aunt

Uncle

Past Medical History

Do you see a doctor regularly for any medical reasons?

Yes

If yes, for what reason?

Have you had any surgery in the past?

Yes

If yes, please list the date and type of surgery.

Have you ever had a colonoscopy?

Yes

If yes, please list date and the results.

Have you had any serious injuries?

Yes

If yes, please list the date and type of injury.

Have you had any diseases or health problems in the past?

Anemia

Colitis

Heart disease

High blood pressure

Lung disease

Cancer

Diabetes

Hepatitis A

Hepatitis B

Hepatitis C

Jaundice

Depression

Cataracts

Glaucoma

AIDS

Kidney disease

Epilepsy

Stroke

Headaches

HIV

Leukemia

Ulcers

High Cholesterol

Hypothyroidism

Hyperthyroidism

Sleep Apnea

Other

If yes, please check any of the following that you have had.

Women's History

Date of first period?

Month

Day

Year

Date of last period?

Month

Day

Year

Number of pregnancies

Number of live births

Are you on hormone therapy?

Yes

If yes, please describe.

Do you do self breast exams?

Yes

When was your last mammogram?

Month

Day

Year

Have you ever had a breast biopsy?

Yes

If yes, how many?

If yes, which breast?

Left

Right

Date of Biopsy(s)

Were there any abnormal cells on the biopsy?

Yes

If yes, please mark the following:

Atypical Ductal Hyperplasia

Breast grouped/clustered calcifications

Lobular Carcinoma Insitu (LCIS)

Are you taking Hormone Replacement Therapy?

Yes

If yes, how long?

Have you taken Hormone Replacement Therapy?

Yes

If yes, when did you stop?

Have you or any family member been tested for a BRCA mutation?

Yes

If yes, result?

How many of your first-degree relatives have had breast cancer?

Mother

Daughter

Daughters

SOCIAL HISTORY

What is your marital status?

Single

Married

Divorced

Widowed

What is your occupation? (or if retired, your past occupation)

Do you used NICOTINE products?

Smoke

E-Cig/Vape

Chewing Tobacco

Have you used NICOTINE products?

Smoke

E-Cig/Vape

Chewing Tobacco

If yes, what age did you quit?

Do you drink alcoholic drinks?

Yes

If yes, how much and how often?

Do you take any drugs for reasons that are not medical?

Yes

If yes, please list

MEDICATIONS/OVER THE COUNTER/SUPPLEMENT

Do you take any medicine (prescribed, herbal, over the counter, or health supplements)?

Yes

If yes, please list below:

Medication

Dosage

How often

Reason

Do you take blood thinners?

Yes

Do you take metformin?

Yes

Do you take aspirin daily?

Yes

Do you take diet pills?

Yes

Do you take vitamin E?

Yes

Do you use a C-PAP machine?

Yes

Do you take glucophage?

Yes

Do you take St. John's Wort?

Yes

Do you take fish oil?

Yes

Preferred Pharmacy

Allergies

FAMILY HISTORY

Past Medical History

Women's History

SOCIAL HISTORY

MEDICATIONS/OVER THE COUNTER/SUPPLEMENT

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